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Get and Sign 2019 Form 1095 C
Insurance Offer and Coverage
5 State or province
All 12 Months
Jan
7 Name of employer
8 Employer identification number (EIN)
9 Street address (including room or suite no.)
10 Contact telephone number
6 Country and ZIP or foreign postal code 11 City or town
Employee Offer of Coverage
2019
12 State or province
13 Country and ZIP or foreign postal code
Plan Start Month (enter 2-digit number):
Feb
Mar
Apr
May
June
July
Aug
Sept
Nov
Oct
Dec
14 Offer of
Coverage...
Show details
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